Include all medical sources that have examined or treated the claimant for the alleged physical
or mental conditions, even if they are not recent. Medical sources should not be limited
to any specific timeframes. The DDS uses judgment in developing medical sources based
on a number of factors, such as, claim type, date last insured, and prescribed period.
Prison records are sometimes a source for medical records. The history in the medical
evidence may indicate the circumstances under which an impairment(s) arose or aggravated
the condition(s). To locate records, follow procedures in the Prisoner Update Processing
System (PUPS) GN 02607.520 and Field Offices Identifying and Documenting Prisoner Status for Title II Disability
Benefits DI 10105.094.
If the claimant received treatment at a hospital or clinic by a doctor or other health
care professional, or if the claimant has a future appointment scheduled:
For any physical condition(s)? (Check “Yes” or “No.”)
For any mental condition(s) including emotional and learning problems? (Check “Yes” or “No.”)
If the claimant answers “No” to both questions 8.A. and 8.B., go to Section 9 – Other
Medical Information. If the claimant answers “Yes” to 8.A. or 8.B., obtain the source
information for the claimant’s medical records about his or her condition(s) that
limits his or her ability to work. This also includes doctors’ offices, hospitals
(including emergency room visits), clinics, and other health care facilities.
Collect the following medical treating source information:
Name of facility or office
Name of health care professional who treated the claimant
Patient identification (ID) number (if known). The patient ID number is essential
to request medical evidence.
Mailing address (complete street address), City, State/Province, ZIP/Postal Code,
and Country (if not USA).
NOTE: Use the telephone book or online directory to obtain or verify names, addresses,
and telephone numbers for medical sources. Always include ZIP codes to eliminate DDS
Dates of treatment (or approximate dates): Include the date of the next scheduled
appointment to a doctor, hospital, or clinic. See, Special Documentation Requirements
– Medical Sources of National Significance DI 11005.060.
Office, clinic, or outpatient visits (collect the dates of the first visit, last visit, and the next scheduled appointment,
Emergency Room visits (list the most recent dates first).
Overnight hospital stays (list the most recent dates first, giving the “Date in” and “Date out” for each stay).
Enter information in the appropriate boxes about:
What medical conditions were treated or evaluated?
NOTE: If the claimant will be seeing a new medical source for the first time, also complete
all of 8.C., including the scheduled appointment date and the condition to be treated
What treatment did you receive for the above conditions?
EXAMPLE: “To get my blood pressure monitored.” (Do not describe medicines or tests in this
Check the appropriate Kind of Test boxes for any tests the provider performed, to which the claimant was sent, or are
scheduled for the claimant in the future. Collect the dates for past and future tests.
If you need more space to list more tests, use Section 11 – Remarks.
NOTE: If no tests by this provider or at this facility, check the appropriate box provided
above “Kind of Test.”
Additional medical sources may be entered in Section 8.D. through 8.G.
If more than five doctors or hospitals have treated the claimant, use Section 11 –
Remarks and give the same detailed information for each healthcare provider.
If the claimant does not have any more doctors or hospitals to describe, go to Section
9 – Other Medical Information.